do there overseas, and that i think is going to be one of the next big jobs of work, of civil rights activists here and elsewhere. >> more questions. rick, second row. >> rick sincere with gays and lesbians for individual liberty. this question is for miss lynns lynnski. one of the memos you showed said the fbi had finished an investigation in 1953 of the mad sheen society and found no security threat. does it say something about the competence of the fbi investigators that they didn't notice that harry hey and will gear and other members were, in fact, communists? >> i haven't come across that in any of our documents, but how about that? >> more questions?

yes, in the very back there. wait for the microphone. >> safe foundation. sir, i was impressed with your presentation. now, i have a more fundamental question about the government of the united states and the people who control this country, the right and the left both together. now, the kind of activities we are engaged in at this time, the spying on american citizens, the entire war crimes that we are committing all over the world, all these things, 20, 30 years from now we will be very, very ashamed as we are ashamed of the things that were being done in the '50s and '60s by those who controlled our government. how do we change this? we are continuously doing such tremendous amount of activities which are inhuman and barbaric.

>> one of the themes and we could have a separate discussion of how bad the conduct of one or another american government is at any given time, but i think one of the themes that we bring out from today is that if you can't speak freely about, it you can't document it, and you wind up wondering decades later you wind up wondering how bad was the government's conduct because they won't let you into the documents that let you find out. now, we found out some unpleasant things about how the fbi operated, and yet when we open the files of agencies like that, it also exonerates them from other things that we thought they might have been doing bad. so we've gone down a long road of openness in government. it has benefited, you know, the fiscal interests of avoiding waste, but it has been tremendously beneficial to correcting the mistakes of both domestic and foreign policy. >> i would just add that the premise for your question illustrates the need for eternal

vigilance, that these fights never end, that you have to continue to look at where rights are being restricted in one way or another, and also since you mentioned the nsa, it indicates why it is so critically important that we have access to information about what the government is doing. the foyer requests for what the fbi was doing in the '50s, finally bringing that information to light, is critical, and with the nsa and the way edward snowden finally brought to light the idea that the government is doing many things that we aren't aware of. now it's comforting i suppose in a way to hear national security officials say, oh, it's very good we have this debate now. i tend to look at it in a somewhat different way, it's usually better to debate things before the government starts doing them to you, but at least we're having that debate now. >> and i would add, i think that's a really great point that you raise, sir, and, you know, it really underscores the work that the mad sheen society of

d.c. and mcdermott are doing together. mico hastings, who is the curator and librarian at the university of michigan clements library said the following and i think it's relevant to your point. in preserving documents and records, archivists have enabled the documents to be revisited and reinterpreted as each era of history reshapes the collective memory. now, she was talking about the internment of japanese americans during world war ii, but that statement is so relevant to really all chapters of our history. certainly with respect to lgbt history we are and we will revisit it and reinterpret it through the years particularly as our sifl righcivil rights ar continuing to evolve. human beings take time to evolve. when you look back at the era of the '50s we think we have progressed so much and we have in many ways. the fact we're having this

public discourse, this conversation, it's being televised is tremendous progress. at the same time look what is happening elsewhere in the world. people who are being killed in uganda because they're suspected of being gay. we've got a long way to go. we have to pass enda. when jonathan was talking about dr. camini, i couldn't help but think, okay, that was 1957 when he was terminated from his job with the federal government, but guess what? a lot of lgbt people can still be terminated from their jobs. we don't have a federal enda. so we're not there yet, either. >> and for the other side of the enda viewpoint, check my article at cato. i wanted to use the moderator's prerogative of throwing out a question because we promised in some of the announcement material to shed a light on the relationship between freedom of expression and historically

marginalized groups, and not a day goes by when you don't see arguments in the press, both here and in countries like britain, that free expression is dangerous to marginalized groups because it allows hate to flourish and allows hateful forces to organize and prop began dies. two examples from england within the last couple weeks. the conservative government has announced a proposal for so-called extremists disruption orders by which the government would be able to go it and forbid supposed extremists from using facebook, twitter, or other social media. they intend to use this apparently against alleged extremists from militant islamists to people who preach racial hate or hate against gays. even more recently a debate was shut down at oxford about abortion, and one of the students who helped to shut it down wrote a boastful article in

"the independent" one of the leading newspaper there is explaining why she was proud of doing so. the idea that in a free society absolutely everything should be open to debate has detrimental effect, has a detrimental effect on marginalized groups. if she was here, what would you tell her? >> who first? well, if we haven't plugged it enough already, kindly inquisitors has a new afterward that's devoted specifically to this and i mention it because it's a very live issue right now. the argument has gained traction, especially in europe, not so much in america, that if enough people start saying enough things that are hateful or just wrong-headed or just bigoted, that creates a hostile environment for minorities. they cannot participate fully as citizens. they become repressed and, therefore, they need protections of various sort and i reject that entirely as a gay man.

there are a lot of reasons for that. which you can read about in the book. vi done enough of that yet? >> author signing afterward. >> but a sentence for each of the two most important. the first is we've got a whole lot of history that shows that minority rights are not safely entrusted to majoritarian enforcers. it just doesn't work. again and again we see this and again and again we see laws against obscenity and hate and religious defamation used against groups that inconvenience governments or authorities or college krens sors or whatever. i halt to think what would have happened to gay people had you had these kind of laws when they could have been used against us as surely they would have been. by the time you have a consensus to have a hate crimes law you generally don't need it. second and more important and going back to the point that the gentleman in the back row made, how do we get out of this stuff? well, the answer is we make

moral progress. we evolve as a species in a morally positive direction towards freedom and human dignity and we do that through a system of debate and discourse. we don't start with the right answer and eliminate the wrong ones by brute force. we do that by pitting prejudices against each other, treating them as a social resource, including the bigoted, nasty, oppressive, and hateful ones, pitting them against each other and trusting as over time it almost always does, that the superior moral opinions will win. that's what worked for gay people and the last thing i would like to see happen is to have people who claim to speak for me and do not have my best interests at heart. >> very little to add. whether or not you're using the government to enforce good ideas or bad ideas, i go back to the words of frank camini that jonathan quoted, that the government shouldn't have power over the mind, and that that is

precisely why the first amendment exists. hate crime laws in europe have done nothing to quell the growth of right wing nationalist movements and yet in the united states where the supreme court has held that even the lunatic rantings of the westboro baptist church and their homophobic protests are protected under the first amendment and that has done nothing to slow the growth of progress toward same-sex marriage and toward general social acceptability of homosexuals in the united states. >> in fact, hate speech helps us. this is something i wish i could put across to the well meaning people who try to help us with all these protections. first, these protections, they confirm the stereotype of weak homosexuals who need help and can't defend ourselves which is not true, but second shts letting the haters have their say make us look good by comparison. that's how we got here. so please spare us attempts to protect us from haters. >> and i would just add that i

think one of the best ways gay people can fight this kind of thing is to be out. stand up and be out, and i realize that for some people it's dangerous to do that. i realize for some people it's damn scary to do that. and i say do it anyway. be out because when a person who claims to hate gay people gets to know you, they may just change their minds about gay people. >> can i ask a question of lisa? you're doing a lot of document requests from i guess a lot of presidential libraries and archives. >> yes. >> what kind of attitudes are you finding 60 years later when you go after this stuff? are you hitting like stone wall and reluctance or are you hitting cooperation and acceptance or what? >> all of the above i would say, right, charles. i would say all of the above. i don't think that the stonewalling, if you will, is necessarily about anti-lgbt

sentiment. i think it's bureaucracy. i think it's red tape. i think it's trying to navigate through a large organization or organizations to find the documents. i don't know that, for example, someone who sends a foia request is having any better a time at it than we are. >> i do think you're onto something. some project you wanted to do that was your own idea and you'd always rather give priority to carrying out your own ideas. yes. in the third row. >> nick little with the center for inquiry. i think it's interesting when you talk about the government controlling ideas because if we

look at lawrence, it was actions, it was about same-sex intercourse. if you look at marriage, it's actions. it's about the action of two men or two women getting married. was there ever an attempt by the federal government to define homosexuality in a way to take it outside of just the controlling of ideas because it cements like otherwise it's a purely mental concept. once you take the actions out of it. >> we deny in my world we deny the distinction is meaningful. the point of sodomy laws in practice, you know, it's targeting a behavior. -- i'm sorry in principle it's targeting a behavior. in practice as we all knew it targeted anyone who was gay who was seen as advocating what was then seen as a crime, soliciting what was seen as a crime. you got fired from your job and you can't be what you are and think your thoughts and go about your life in a meaningful way if you are under threat of

political persecution for acting on that. so it's like saying, okay, well, look, you can be okay believing in the tenets of judaism. you can't go to synagogue and you can't practice. that's where we draw the line. no jew would say that that was a meaningful disdistinction. i would in that sense push back against the premise and say it's all or nothing. >> front row, greg. >> thank you. gregory t. anglo with log cabin republicans. i wonder, john than, you're correct -- well, i agree with you i will say that we haven't experienced that much blowback in the wake of the marriage equality rulings but what we have seen if anything is all these years after this one versus olesen case, people who are christians who are claiming similar freedom of speech protections when it comes to photography, baking the wedding

cake. so i wonder, and this question is actually open to anyone on the panel, if there's -- if you see the supreme court having to consider a similar case about freedom of speech and how that impacts an individual's perhaps right to discriminate in those cases and if that could inform the supreme court's marriage equality ruling if they do take unthe case in the next session. >> this is something that has been of continuing interest to the cato institute which has filed amicus briefs not always successfully on behalf of wedding photographers, for example, who had objections -- religious objections to serving same-sex weddings. psychologically you can imagine that supreme court justices might be worried about both issues at once. that doesn't mean that a case will present both issues for resolution at once, but the feelings run very high out there

among commentators on the idea that once you have a discrimination law on the books, that it's supposed to be as sweeping and have as few exceptions as possible. it's not clear to me that the supreme court is ready to stand against what seems to be the spirit of the age on the more anti-discrimination laws the belter. i wish it would because i believe these laws would be better if they had greater play for individual autonomy and choice, but that's not been a big theme of the courts' rulings in recent years. >> i would just add that your question focuses on that sort of growing tension between anti-discrimination and freedom of expression. i think you can ask the question, could an editorial writer be forced to write an editorial praising homosexuality? of course not, that would be an obvious first amendment violation. i think you can say the same thing of a photographer who is

compelled by law to practice art in favor of a lifestyle that person does not want to associate with. it can extend to a baker. again, there is a tension there, but i don't think you resolve that tension by having the government come in and be the referee and decide who is going to be compelled to express themselves in a way that the government now decides is the acceptable -- the one acceptable way. >> currently you do have the government in new mexico and elsewhere coming in to make just such decisions. >> which gets backto that eternal vigilance i was talking about. >> more questions? there was one -- okay. yes, sir. >> bob spiegel, member of the board of the stone wall veterans association and former member of the board of the american civil liberties union. i waited to the end so i could go through a few points to ask my questions. >> brief questions only, please.

no speeches. >> then my question is there are many people who believe that hate crimes statutes implicate the first amendment, and it would appear that many in the gay community support what would be called a hurt feelings exception to virtually every provision of the first amendment. so i'd like to hear the panel speak about those two issues. >> hate crimes and hate speech, two different issues. anyone want to start? >> well, first of all, we have to start with definitions. hate speech, what is that? basically it can be whatever someone finds offensive, and that's why there can be a significant tension between wanting to have a civil society and forcing people to limit their speech. greg is sitting here in the front row. ease the president of fire, the foundation of individual rights and education. one of the continuing battles of that organization and i'm proud to asirs with it is to address

campus speech codes where you have basically the enforcement of civility on college campuses, meaning it is what greg calls an offendedness sweepstakes. people who are offended by, well, you name it, anything, can then appeal to the sanctions of these very broad and indefinable codes to put a clamp on whatever speech they don't like, and you see that in the wave of commencement speakers who are being disinvited during what f.i.r.i. calls disinvitation season if they are going to speak on something that is considered to be politically inconvenient or that evoke a minority on a campus or even evoke a majority, it doesn't matter, considers to be wrong headed. i think that there needs to be a greater recognition as jonathan was saying for protecting the speech that we hate because then you have a true debate and people in a free society can

decide for themselves what they want to believe. >> so i take the question to be about hate crimes laws as opposed to hate speech laws. >> many people believe that hate crimes laws -- >> i think they do. hate crimes laws for those who are not on top of this are a bit different because they -- essentially they are additional penalties for people who commit crimes against minorities and are motivated by hate. i think they implicate the first amendment. i don't think they're as clear cut and i don't get nearly as worried about them as i do hate speech law which punishing speech per se because in hate crimes laws you're punishing things that are already punishable anyway and you're debating the length of the punishment. i think it's rotten crime policy though i do worry a bit about first amendment. i think the premise of your point was a lot of gay people

favor these protections, is that it? >> yes. >> and that is certainly true, but here is the thing. my experience has been that gay americans are no less supportive of the first amendment than other americans and that the broader issue is my very first managing editor at my very first newspaper job said if you put the first amendment up to a plebiscite of the american public today, it would lose. so that's the ongoing educational struggle that i do with my gay friends and i do with my straight friends just as well, which is every generation has to be taught afresh that the very counterintuitive proposition that we should specifically make room in society for the most vial things that people think and say, that's got to be taught all over again every year. it's easy for us to forget in 1791, bill of rights, when james madison put freedom of speech number one, this was a completely radical, untried idea

in the entire history of the world. i mean, no one had even thought you could have a government without some methods to control speech and thought, and it's still deeply counterintuitive, but, yeah, i don't think it's harder among gay people than straight people. >> part of bob's presentation, i had meant to note at the time was remember the victorian standard of obscenity which was not as later changed in roth, not whether it would tend to corrupt the average person but whether it would corrupt what you might call the egg shell corruptee, the most susceptible, the most fluttery person and if it would corrupt even that one person, it was too obscene to be allowed publicly. we have revived that with the new law of offense. the test for whether a career is ruined or someone is allowed to speak on campus is not whether what they say would offend the average person but whether they

would offend the egg shell offendee. i don't think it works in either case. we are about ready to adjourn for lunch. let me give you some directions on that because it involves going up two flights from here to the george m. yeager conference center. you can do it either by crowding into the elevators, which may take you a little longer because of their capacity or simply walking up the spiral staircase two flights. if you are looking for a restroom when you're on the second floor and are walking toward the conference center, you will notice a yellow wall. that's where the restrooms are. i will see you there for lunch in a few minutes. please join me in thanking our wonderful panel. [ applause ]

[ applause ] news from the administration today. defense secretary chuck hagel resigns breaking the story, "the new york times" saying secretary hagel is the first cabinet level

position casualty. in the official white house announcement earlier today with the president and vice president, secretary hagel called his service the greatest privilege of his life. secretary hagel became cabinet secretary when former defense secretary leon panetta stepped down. before he served his home state of nebraska in the senate from 1997 to 2009 where he became close with then-senator president obama. secretary hagel is the first enlisted combat veteran to be defense secretary having served in vietnam. he will stay on the job until his successor is confirmed by the senate. harry reid said this today about secretary hagel. it is my hope that senate republicans will work with democrats to give swift and fair consideration to president obama's next nominee to this critical post. and speaker john boehner said this, this personnel change must be part of a larger rethinking of our strategy to confront the

threats we face abroad, especially the threat posed by the rise of isil. thus far this administration has fallen well short. and we'd like to hear what you think about defense secretary hagel's resignation. you can post your reaction on facebook at facebook.com/c-span. also we'll be looking forward to reading your tweets using #c-spanchat. this thanksgiving week c-span is featuring interviews from retiring members of congress. watch the interviews tonight through thursday at 8:00 p.m. eastern. >> people say, oh, hinges have become so partisan. well, tell that to some of the people involved in congress back in the 1830s to 1860 period, henry clay or certainly stephen a. douglas. these people were struggling desperately to try to work out

compromises to keep the union afloat and avoid it splitting up. >> i think we have a lot of talented younger members, and it's not just, by the way, mrs. pelosi. i think she's been a great leader, and she is really good at raising money. that's not one of my fortes. i was never good at that, but they have to start training younger people and bring younger people into the caucus to become hopefully the future leaders. one of the things that i certainly believe with all my heart and soul, you have to know when to leave. >> and also on thursday we will take an american history tour of various native american tribes. that's at 10:00 a.m. eastern following "washington journal." then at 1:30 attend the ground breaking ceremony of the new diplomacy center in washington with former secretaries of state. and supreme court justices clarence thomas, samuel alito,

and sonia sotomayor at 8:30 p.m. eastern. that's this thanksgiving week on c-span. for our complete schedule, go to cspan.org. coming up here on c-span3, a brookings institution forum on health care policy and accountable care organizations or acos. these groups of doctors and health care workers aim to provide quality care while minimizing costs for patients, medicare, and medicaid. we look at the curb rent sate of acos and we bring you a discussion of issues and challenges facing these organizations. we'll hear from centers for medicare and medicaid administrator mark mcclellan on controlling health care costs. [ applause ] thank you and good morning. i'm going to speak for about 15

minutes and then leave about half the time for questions and answers. partly because that's what mark asked me to do. but partly in recognition, i looked at the other panelists and the people here in the audience and i think very distinguished group and groups like this people like me from the government should do less speaking and some more listening. so my remarks, quickly i want to give you some big -- very big picture context of how we think of the shared savings program. so starting at 40,000 feet and then coming down fairly quickly to the ground level and talking, as mark indicated, about we are in development of a proposed rule for the future, the next generation of the shared savings program. let's talk to you a little bit about where that might be headed. so first, we're about four years out from the affordable care act and probably more importantly we are one year out from the 50th anniversary of the medicare statute passed in congress, 50 years ago. on -- so where are we?

on the most important measures, which are controlling the costs and improving the quality of care that our beneficiaries receive. on controlling costs, the news is historically good. we are in the middle, about a four-year period where the cost per capita of providing care to a beneficiary is essentially going to be flat for four years. some of that is data that is already in. some of that is the actuary forecast for next year. unprecedented performance on reducing the growth and cost per care. that bodes well for the program in the many ways. one, the trust fund, the life of the hospital insurance trust fund. if you go back to 2009, the forecast was that it was eight years from being exhausted, that it would be exhausted in 2017. this year the trustees are saying we're 16 years from being exhausted, that the life has been extended to 2030. so that's good news. also i think when you control health care costs, it allows not just relief for the federal deficit, but also allows for better health care policy. probably the best example is

serious discussions now about getting rid of the sustained growth rate provision in the medicare statute which many feel has outlived its usefulness, but that the discussion to get rid of it is only made possible by the low cost in medicare spending. so that's the cost side. on the quality improvement side, again, historically good news. hospital acquired conditions, many forms of hospital acquired conditions are dropping. ventilators, associated pneumoni pneumonias, early elective delivers, i could go on and on. lots and lots of signs of improvement and care in our beneficiaries are receiving. hospital readmissions dropping. one in five medicare beneficiaries, about 19.5%, readmitted to the hospital within 30 days of being admitted. that is now in a precipitous decline, now at about 17.5%. so what is causing all this good news? there is a lost factors. some is public policy, predating the aca and out of the affordable care act. some of it has nothing to do with public policy.

it's changes that the professions and the hospitals and the delivery system have made on their own because i think what you see is the beginning of a genuine quality improvement, performance improvement revolution in health care which we've had in other industries but sort of late coming to health care. we see actions by other payors, commercial payors, state medicaid programs that are incentivizing these changes. so we're in very good position. we have challenges ahead. how do we continue this level of performance and improvement. first of all, the challenges ahead are significant. one, the actuaries, although they're predicting medicare costs will continue to be flat next year, when they look further out, 5% inflation every year. more of a challenge is the baby boomers. in the next 20 years -- we have 50 million give or take medicare beneficiaries today. in the next 20 years wield add another 30 million. so 60% growth in the next 20

years. very substantial challenge even if we continue to control growth per capita. so that's sort of the landscape that we view the program in. we're in a great position in controlling costs. we have made significant strides in improving quality but we face very, very significant challenges. so i think that the way we look at the landscape is we need to continue to support delivery system reform and how do we do that? the secretary burwell within her first 100 days articulating a vision of delivery system reform which was providing information to providers so they know how to improve and where they need to improve. improving the incentives, making sure all of our payments support improvement. and building capacity within the delivery system for improvement. and i think the aca has already initiated a lot of that work. if you see on the quality side on information, we're providing quality measurement in almost every one of our provider groups that are in medicare.

we're providing transparency with publishing these on our websites, whether it's nursing home compare, hospital compare, and more importantly, and this is where i wanted to get to, is we're injecting the notion of value, of paying for quality and efficiency into all of our payment systems. and what are those payment systems? very briefly we have the medicare advantage program, we've got the fee for service program, and we have new models of care that mark referenced. in the medicare advantage program, a lot of progress. the affordable care act i think set us on a course to pay more reasonably so we're getting significant savings there but at the same time we're getting higher quality care in medicare advantage. 60% of medicare advantage beneficiaries next year will be in four and five-star plans. premiums have been essentially flat since the passage of the affordable care act. fee for service, hospital value based purchasing, physician value modifier, even in dialysis payments, we're building in the concept of paying for quality,

paying for efficiency into all these fee for service models. as mark said, for many providers they believe to truly achieve change in to fundamentally change the way they deliver care, they need to move out of fee for service and move into a different model and that's where acos and other models come in. i'm not going to go into depth unless we get questions but the innovation center is testing any number of models around acos, primary care medical homes, lots of variations. i'll focus ona cos but as i say it's an important part of our strategy on new payment models. where do we stand on the aco program. early results and i would use very similar slides to what mark did. the early results are very promising, particularly on the quality side. on the quality side it's clear the acos have figured out how to improve care and we see that in beneficiaries. one of the measures is patient satisfaction and patients in acos tend to be more satisfied

with their care than patients who are not in the acos, but there's more quantifiable measures. the pioneers from one year to the next improved collectively on almost all objective measures of quality. i think 28 out of the 33 measures they improved on. in the shared savings program the shared savings acos outperform fee for service in 17 out of the 22 measures where large group practices had reported quality measures. on the quality story, very good, promising results. on the cost side, a little less -- more of a mixed result so far but i would caution that it's very early in the program. you recall if you went back to january 2012, there essentially was no such thing as an aco and now we have as mark said -- i usually use the number 360 in the medicare program but many more in the private sector as well with 5.6 million beneficiaries participating in them. several pioneers have clearly

figured out how to generate cost savings and do that consistently from year to year. a number of shared savings acos as well. but the story is still mixed, and the question isn't can the leading edge figure out how to generate cost savings but can we get the vast majority of the acos in the long run generating cost savings to go along with the quality improvement. so if the situation is promising but needs to do better, how do we move forward? again, i go back to the secretary's vision. we need to improve the incentives that the acos receive, improve the information, and help build the capacity of the acos. since, as i mentioned, we're developing a new regulation for the aco program, i can't tell you specifically. what i will talk about now briefly are some of the areas where the private sector, thea cos, have come to us, including through the brookings learning network and have told us areas where they think we could improve and they map certainly to the incentives, the information, and the capacity

building. on capacity building, we've heard a lot of small practices that want to get into acos or are in acos need help in understanding how to transform themselves. we've heard this outside the aco community. how do we help small practices in clinical transformation. that's something the federal government is talking a lot about. we even have spoken publicly about and solicited ideas, how could the federal government support small practices in transformer better. one of the things we have heard is since this is fee or service medicine, when we assign a beneficiary to an aco in one year, many of them are not assigned in the second year. and then what some have referred to that as the churn of beneficiaries. it's harder for the aco to focus their intervexes and resource investments on a beneficiary if they're not certain that they're going to have that beneficiary in the long run. and i think mark made reference to some of the savings opportunities are in the long

run. so we've been talking to the private -- to many of the acos and thinking about how to get a more stable population for the acos. the challenge is this is fee for service. the beneficiary is not locked into a network in the current vision of what an aco is. and then bradley i think how you go get nonchurn something part of a broader category of how do you get more beneficiary engagement. i would say this is true not just in thea co context but any context in which the provider is trying to provide care better and in a different way. how do you get the beneficiary engaged in their care so they're doing self care, following medication adherence. on information we heard consistently that acos need better and more timely information. we've been working hard to do that. we have a ways to go. i would say though for the cms' behalf, two years ago we were

sharing claims data with nobody. now we're sending monthly claims feeds to over 300 acos every month on -- with data of over 5 million beneficiaries. this hasn't been an enormous change for what the cms saw as its roam but it's been a successful one. it has a ways to go and we can figure out better ways to share information. most importantly we've heard quite a bit of talk about changing the payment rules for the acos. when of the things we do is we continue pay on the first dollar of shared savings because there's a lot of variation year to year in medicare spending. we create minimum savings raich yos which is the first couple percentages considered just statistical background variation. many acos have balked at like. they'd like to be paid for that. one of the things that's implicit in all the numbers mark

shared on who generated cost savings is what is the formula for what is cost savings. you start with the cost of your own beneficiaries historically but you trend that forward based on what happened nationally in the medicare fee for service program. a couple thing to observe about that. one is it's an interesting time to have started the aco program because the fee for service has essentially not been growing at all. it's a difficult benchmark to meet regardless. two, a number of acos have said i'm in a community where costs have been growing faster than the national average and it's not fair to give me a bench mar that only grows by the national average. we've been listen closely to these, but this was the point of contention in the drafting of the affordable care act and it's a very delicate regional balances that come out in those discussions but we are hearing quite a bit about whether the

benchmarking methodology is the one we should say with. we are proposing acos that generate savings and then continue in the program that we would do something called rebasing which is we're using a historical base period, we'd roll that base period forward. some acos feel like if we keep rebasing them their opportunity to generate savings will be diminished. we're being asked to not rebase or approach it differently. mark made reference to a lot of acos want to provide care differently in ways that aren't paid for by the medicare fee for service program. and they can do that but they're not paid on a fee for service basis when they do that, so essentially they're investing their own funds. we've been asked by the aco community for a number of waivers, meaning they don't want to have to follow the three-day prior hospitalization rule in medicare. they want more generous access to the home health benefit, and then finally and probably most

conceptually tricky is, as mark said, many of them want to not be paid during the year on a fee for service basis but would prefer to be paid on a capitated basis and that would free up the dollars for them to do a lot of innovative things. as i say, it raises some conceptual challenges which is would the acos then be like an ma plan making payments to other providers? would it imply there's a network? but these are all interesting ideas and they're ones we're taking very seriously and considering as we propose a new rule. we're hoping the new rule will be out shortly so that the public could comment on it. we will go through the normal public comment period which this would be a proposed rule. we would solicit comment and adjust the rule as appropriate to public comment and hopefully have a final rule early next year. but again this is, in conclusion, this is a major part of our strategy to continue the improvement on controlling costs in medicare and improving quality. it's part of an array of strategy that is range from

medicare advantage all the way to our fee for service payment systems, but it is one of the keystones and one we're looking forward to working on with all of you. so with that, i will pause and take any questions. and i'm almost right on time. [ applause ] >> so while sean is getting switted, there's a little microphone he can clip right on there. i'll just start with the first -- framing the first question, sean. you did a very broad overview of fitting the a krsaco program in wide range of payment reforms taking place in medicare program generally and cmmi in particular. one of the things that you highlighted was basically that -- how important it is to think of acos as not just about a payment model, that there are other changes that are needed, too.

you talked about a lot of the regulations in medicare's payment systems on things like no requiring a three-day stay at a hospital before going goito h health care. uses of home health services have typically been limited because of the restriction -- because of the fee for service nature of medicare payment. and you also talked about the need for further steps, especially for smaller accountable care organizations or smaller provider groups to be able to get off the ground in these kinds of big payment reforms. i know that more of this is going to come up in that regulation, which is coming out soon. >> soon. my official position. >> but you have made some other announcements recently from cms and the administration has that pick up on some of these other issues. for example, just recently advanced payment plan for rural acos. i'm wondering if you could talk more about that.

maybe about recent announcement from the office of the inspector general i believe about extending the program to give acos and some other providers participating in these new arrangements a bit of a pass from some of the restrictions on sharing money across providers and the like and sharing resources across providers that, again, are intended to block some challenges in fee for service that may be less of an issue in these coordinated care approach approaches. wondering if you could talk about how you see acos in the context of other policy changes and where those might be headed as well. >> sure. and thanks for that question. and, again, it was just part of what i was trying to say in my remarks is acos are important and they're big and a growing part of the program but they're part of a broader strategy to improve care and reduce costs. on the specific topics you raised, we had as some of you might know, created at the start of the shared savings program something called the advanced payment model. this was to recognize there were

a lot of provide whose looked at the shared savings program and said i get it, i think that's the right direction for us to go in. we can do well by our patients. we can improve the quality of their care but we see it requires an up front investment but we're just a group of small physicians or rural hospitals. we don't have the capital to do that initial investment and so for want of that initial investment, we won't be generating savings for years to come and improve quality. so to help some providers get over that hump, we provided what's called advance payment which was -- the name was chosen carefully because what it meant was this is an advance on future shared savings you're going to generate. we gave it to 40-some acos and we said here is some money to help you through the beginning to hire care coordinating nurses, beef up your i.t. system, but when you generate shared savings you will pay this money back to the federal government. it's been very popular. some of them did very well in the early rounds of the share

savings program but we also heard that we left some groups on the outside when we designed the original one. we also heard that some shared savings acos were able to get into the program but weren't sure they could remain in the program without some help. so we tried to design the new round of advanced payment to capture some who were in who wanted to stay in but needed some help but also rural hospitals. i think we really didn't define it right to get rural hospitals in, particularly critical access hospitals. on the waivers you were referring to, when we created the program initially, if you can think about the shared savings program, these are often not already integrated health systems coming together. these are independent practices and fqhcs and providers coming together for a common purpose but often times when they do that, they run up against some existing fraud and abuse laws about how much they're allowed to cooperate. so the original program included some waivers from fraud and

abuse laws. those waivers were due to expire this year and the office of the inspector general has extended them for a year and i think -- i think once we come out with the where the program might be headed, i imagine everybody will go back to the drawing board and decide do these existing waivers still fit the new program. >> it does sound look a longer term commitment to making sure the fraud and abuse protections are appropriate for the payment systems being used. >> yes. i think you'll see continually as the program evolves, continued re-evaluation of have we tailored them correctly to the way the program is operating and to what providers need and what the government is comfortable. >> in the same spirit of reinforcement of the basic ideas in an accountable care payment arrangement, we're seeing in private sector are a lot of insurers putting in a number of different reforms at the same time, so not just acos with shared savings or two sided

risk, but also medical home payments, bundled payments for special services and more advanced care, a number of payment reforms that all can be reinforcing. it will be challenging when medicare is trying out some of the new payment models and trying to figure out what the effect of each one is. i think what many of the private payers are finding they get more mileage by putting them all in together. is that something that you all struggle with in terms of -- >> we do. but as you know, the innovation center is testing many different models, we have tried to allow participants to participate in multiple models. there is one statutory prohibition, which is provider cannot participate in more than one model that involves shared savings, we try to be cognizant and enforce that. but other models we think could be complementary. it does pose a challenge as you

say for the proper evaluation of if you see a positive result, disentangling what contributed to that result. the one promising thing there is with the creation of the innovation center, we have much more robust evaluation of budgets than we have ever had in the past. so we'll do better, it will still be very much a challenge though to disentangle those effects. >> we'll open this up to comments to those of you in the room. we have microphones. if you put your hand up and wait for a microphone, i'll try to get to as many people as possible. and over here, someone had their hand up first. i'll wait -- just a second. >> thank you. jerry anderson, johns hopkins university. sean, you mentioned the evaluation budget.

you have a whole series of evaluations ongoing at cmmi. some programs are working. some are them are not. what are the commonalities of the programs that are actually saving money? >> first i would say -- i think i'm being rewired. i think it is too early to say. i apologize, but, you know, innovation center's first models went up january 1st, 2012. so, you know, to see measurable results, best case scenario would have been like this time last year. that's if they had immediate substantial impact and even then it would be limited to the pioneer acos and the partnership for patients which is a big quality improvement. but the bundled payment for care initiative is getting off the ground now. some models we have early

results. speaking qualitatively from what i've seen and not applying the level of rigor you tried to teach me at johns hopkins, i think what you see is it is providers who are in this mode long before the affordable care act passed, meaning providers who saw the problems with fee for service medicine, but were pursuing the right form of care, communicating well with other providers, staying close to their beneficiaries, focusing particularly on the high risk beneficiaries, long before all of our payment systems might have caught up to that seemed to be the ones who got going right out of the gate and did well. those of whom are responding to the new incentives i do think there is a learning curve. i think -- that's why when we talk about the shared savings acos, i think you have a mix of those. you have some that are coming in saying, this is great, this is what i always wanted to do and some saying this is great, this is what i've always been doing and now i'll get rewarded for it. so i think early on you're going to see that diffusion of performance, but the hope and expectation is that the big middle will catch up.

>> for those early -- those early organizations that were committed early to this kind of approach to care, it is still important, though, to be able to have a sustainable business model to do that. and do you think the shared savings program is enough to get there, is your sense from many of those that they like to do more in the way of payment reform? >> again, i think there is a huge diversity out there. there is certainly a leading edge of acos that want to move as fast as possible to more financial risk, meaning almost capitation. though they tend to want to get away from shared savings, meaning they want to budget a perspective budget, they want

capitated payments based on that budget, and they want to, you know, let the government take a couple of percent off the top as a discount and then on their way. i would say that's a small minority, but very large, sophisticated organizations. i think there is a larger group that are still feeling out what is the business model and what do they need exactly. but many of them clearly want better upside potential with less downside. >> time for another question up here on this side. >> thank you. my name is lee young. when we are talking about the budget or whether there is care, i have a very strong concern about it based on my research about hospital utilization and based on personal observation. i just wonder if you can address issues about accountability and the record and real patient care.

it's more workable. in writing the response is totally absurd. and then you have abuse and unnecessary -- or even mental care. they have a private patient rights advertising they will pay by the hospital, but they are really -- if you don't address this couple issues, the whole thing is meaningless. so could you -- >> i think you're making what is a point that i should have said at the beginning, which is our focus on cost containment needs

to be matched by our focus on quality improvement. i think we have tried to do that, but you're right, anytime you create a new payment -- every payment system has incentives. whether it is positive or negative, whether they move you in the right direction. but when you create payment incentives to increase efficiency, you need to have some confidence that your quality measures are making sure that efficiency doesn't come at the expense of the patient. with that i would say, you know, the results at least so far in a shared savings program are very promising. patients are happier, seem to be getting better care. whether it is the shared savings program or elsewhere, i think our measures of quality have a long way to go. and i think they have come a long way, but i think there is a long way to go to make sure we're measuring things we care about and capturing -- the other tension i would say is there is attention in the shared savings program between those two would want to measure everything, meaning we don't want any possibility of something adverse is happening to this patient, versus the acos saying don't drown us in reporting and

measurement, allow us to focus on things that are really mattering, that are a handful of really salient measures. and i think that tension hasn't been fully resolved. >> right. one that is part of the reason why you're doing so much work to try to expand out the scope of measurement while still reducing the burden on providers. point out there are a lot of aspects of patient safety where it is very much aligned with the reforms and accountable care. so preventing rehospitalizations, avoiding costly medical errors that lead to complications, all those are steps that i think accountable care organizations, like the hospitals that you mentioned, now that the payments for admissions are being reduced, those organizations have

stronger incentives to address. are there any particular areas where you're worried about the other direction, that the higher quality care may actually be more expensive, maybe for some special -- some special conditions where there are expensive treatments needed, any particular areas stand out there? i know you're generally trying to pay attention to these issues. >> yeah. what i would say about that is we have had some technology firms, some medical device firms come and say, you know, this new payment is wonderful, but you're going to squelch innovation. and what we have said is, you now, we don't want to squelch innovation. there is a type of innovation as you said that reduces costs. even the ones that may increase costs but that are life saving or life enhancing, so we're trying to find ways to measure that. we have been working closely with those industries to try to see if our payment system should adapt and allow -- they asked for a pass through meaning. we come up with something new, don't include it in the reconciliation whatsoever. we're not willing to do that. but we're continuing to focus on that to make sure as you said we're not that particular type of innovation isn't being -- >> i would like you all to join me in thanking sean cavanaugh for joining us here this morning.

sean, thank you very much. [ applause ] >> tonight, academic freedom and free speech at colleges and universitieses with anne neil of the american council of trustees and alumni at the city club of cleveland speaking about commencement speakers who decline to attend or are disinvited from ceremonies after student protests. watch at 8:00 p.m. eastern on c-span3. >> announcer: with live coverage of the u.s. house on c-span and the senate on c-span 2, we complement the coverage with the most relevant public affairs events and hearings. on weekends c-span3 is home to american history tv with programs that tell the thags's story including six series, the civil war's 150th anniversary, visiting battlefields and key events. american artifacts, touring museums and sites to discover what artifacts reveal about

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our next panel and ask our panelists to come on up to the stage. we're going to talk now about in terms of the state of accountable care, what we know about aco so far. so this panel is going to explore in a lot more depth the kind of evidence that you heard about briefly in my introduction and in some of shawn's comments. the evidence on aco implementation, practice and results. while our panelists are getting seated, i'd like to introduce them. they include michael randall, the vice president of clinical innovation for advocate position partners in chicago. he previously served as manager of business advisory services and hospital operations for the camden group, a consulting group that provides support for business planning, financial advisory and compliance and hospital and physician services. next i'd like to introduce marcus zachary, senior medical director for quality and population health at brown medical group in california. he's primarily responsible for the strategic and operational oversight of medical services

related to the ambulatory care u network at brown and the aco portfolio, which includes their medicare pioneer program. within brown, dr. zachary helps design and drive initiates linking quality and information technology in pursuit of the goals of improving quality outcomes and reducing costs. before being at brown, dr. zachary was lead physician working on implementing electronic records for a hospital in san francisco. next is jay michael mcwilliams, glad you could join us today too, down from boston. associate professor of health care policy and a practicing general internists. his research, he's an m.d. and ph.d. focuses on quality access

and disparities in ageing populations with chronic conditions. the overarching goal of michael's work is to inform the development of health care markets, delivery systems, insurance coverage and regulatory and payment policies that support value in health care and in medicare. much of his work relates to evaluating accountable care programs including the massachusetts blue cross alternative contract. and finally, david mulesteen is the director of research. it's a health care intelligence business where he oversees the firm's quantityive of the changing health care landscape. he studied the growth of accountable care organizations extensively with center for accountable care intelligence and he leads the firm's study of health care markets. his research interests focus on applying legal and legislative framework to evaluate the evidence of health policies for the benefit of government, and private policymakers. now, i've asked each of our panelists to start out with some

opening comments for this session on how they see the evidence on acos emerging. any particular challenging areas, notable findings, what they'd like to see happen next. comments along those lines. and we're going to have some discussion across the group, and then with all of you here today. so, if i could start with michael randall, please go ahead. >> so, first to start, advocates, we're excited to be here to share our journey with you. i lead many aspects of advocate strategy and operations, in total we serve about 600,000 lives in our aco. this includes commercial, medicare, and medicaid lives. in terms of how do we make the model more sustainable, i think you've heard some things that medicare is looking at. commercial payers are also looking at. how do we design a model for shared savings that is able to support provider organizations

to have funds available to invest in information technology and care model design. before i get into those aspects in particular, i just wanted to share some of our results both in the area of quality, and also cost savings. so first in terms of quality, medicare shared savings side, we had our estimated total quality score, we saw that increase in 2012 from 79 to 86% in 2013. of the scored measures, 21 of the 27 improved during this period of time. on the commercial side, also seeing improvements in quality. we track eight key indicators for our hmo population. six of those eight improved in 2012. we're still finalizing results for 2013 but overall a net positive improvement. 2013 was a baseline steady for

our ppo population. on the cost side, our results mirror that of the national experience for the commercial plans, both hmo and ppo. we're seeing a year over year improvement of about 1% to 3%. for medicare shared savings, a little bit less. but our first performance year was a 0.2% improvement ahead of the national bench mark. all of which came in the last six months. that equates to about a 0.6% improvements. or about $3 million in net savings to medicare trust fund. to make the model more sustainable we believe that there are two areas of focus. one is information technology. and the second is care model design. so in terms of information technology, it's very helpful to have a claims information, it gives us a glimpse into the total care that patients are receiving, but it's not enough.

and so, for us, we're focused on marrying up the clinical and claims information. one example of that has been our partnership or collaboration, rather, with sernor where we developed a new hospital readmission risk tool that has a predicted value, that's 20% better than anything else on the market today. a second example of how we're trying to merge clinical information claims data is our support of the development of a regional health information exchange. advocate supported this through leadership, as well as investments of funds, and in the model design of the regional information exchange. anticipating about 50% of their hospitals will be participating in this by the end of the year. starting first in the exchange of admission, discharge and

transfer data with clinical information to flow about the middle of next year. the second area to address is care model design. like other organizations, we started by focusing first on our high risk population. we designed an outpatient care management program today that employs over 100 care managers, working in the field with our physicians to coordinate care for these patients. a second key program was investments in post acute care services. development of a pan sniff network. advocate only owns one skilled nursing facility yet we refer business to over 100 independent skilled nursing facilities throughout chicago. and so for us to be successful, we had to identify those organizations that shared a common vision to prove quality and lead to greater efficiency. looking forward, we recognize that we need to go deeper into the population health triangle

to engage not only the high risk, but the moderate risk patients, as well. we've done some of this through our patient center home implementation. we are implemented this past year three new pilot programs. one of which is a community health work care program and as we look at 2015 we will be making additional investments in pilot programs. i think for you in the audience that has the ability to influence public policy or commercial development efforts, supporting the efforts to promote interofferability of data, and the exchange of data, as well as research to understand what truly is having an impact, and what's working, would be there as a focus. thank you so much for your time. >> great. thank you very much, michael. and i'd like to turn next to dr. zachary. >> thanks for having me. i'm marcus zachary from brown and toland. i'm having a disconcerting moment that i'm the gray-haired guy up here on this panel. i guess i've reached that age. so for those of you who don't know, because there's not a lot of folks in california here, brown and toland is a fully physician owned and operated independent physician association, the largest in northern california, over 1700 docs. so we are truly hospital agnostic. we have no private equity

partners. we have no hospital financial partners. we have a long history of managing mostly professional risk, and a capitated environment. we, like sean was saying, are interested in taking more risk, and so with payment reform that was happening with the aca we jumped right in. we have shifted about 100,000 lives over the last three years into some form of risk sharing program. and that runs the gamut of alphabet soup, we have hmo, aco, ppo, aco, we've got a limited scheme for taking first dollar on medicare advantage patients, and then of course we're pioneer

for participants and happy to say we were one of your red dots up there where we've achieved significant savings, actually, in the first two years of payout with good quality outcomes. and we're very proud of that. i think on a high level what we'd like to see, you know, i think one of the things is, that i worried about from the beginning, is that if the payers' attitude is, what have you done for me lately, i think we're going to be in trouble. we're coming from double digit inflation in the health care space and now we're talking about actual savings. and there are a lot of inefficiencies, and there is a lot 6 of opportunity to raise the sea level but at some point, it's only going to go up so much.

and we will have to i think, accept the fact that there will be some growth for inflation. also taking into account, again sean was actually quoting the exact figures. we know the baby boomers are really going to put a stress on the health care system financially, and resource-wise. so i think there has to be some dose of realism that the remarkable performance that we've seen early on at some point that's going to regress to the mean. to some extent. that doesn't mean we have to go back to double digit inflation. but, something realistic. and then, i think the other thing, and this is just from brown and toland's perspective, because we have been managing risk and our docs are used to it, we definitely would like to see the continued evolution for the opportunity to take on more risk and to get at that first dollar which i think sean was sort of alluding to. it's not going to be for everybody and i would caution anybody thinking about it to

really understand your organization and your ability to handle that risk because it's not easy. when we get into questions i'd be happy to talk about tactics and strategies that we're using sort of more into the weeds that seem to have been important to our success. but i think i'll leave it there for now. >> great. thanks very much, marcus. we've heard about results to date from the standpoint of a couple of the major organizations that are participating in aco efforts in both public and private sectors. and now we're going to hear from a couple of the experts on looking at the bigger picture across all of the aco experience in the u.s. so far. next up for that i'd like to turn to michael mcwilliams. michael? >> so i'll speak more from a research and policy perspective as mark said. and i'll comment on three things. two challenges, and one as far as results go. and i think one of the key challenges ahead from a policy perspective is getting the benchmarking methodology right, the spending targets for acos. under the current model, the

incentives for acos to generate savings are quite weak. particularly because of the rebasing that's implied by the current rules. so if an aco achieves spending on one contract period, carrying the current rules forward that would mean that their spending target or benchmark for the following contract period would be lower by that amount. so to give you a sense of why that really diminishes the incentives, if you think about an aco increasing spending during a contract period, medicare shared savings program, aco for example that isn't facing any downside risk, they are penalized for doing that. and it increases their benchmark for the following contract period and then they can receive a shared savings bonus for doing nothing. under the pioneer program, they are penalized for doing more, but again there's that offsetting effect by the benchmark going up and the subsequent contract period, so for pioneer acos the incentives are more akin to fee for service with a lag. then, thinking about the fixed costs of investing in systems to actually control spending, the

rebasing is that much more of a problem because it may be hard for acos to recoup their investments of investing in the right systems. so that is one challenge. and i know sean and his team is working hard on a revamped proposed rule for the shared savings program. another challenge that's related is unless acos have more control over where patients get care in the aco programs that diminishes the incentives further. to give you a sense of that we analyze outpatient care patterns at baseline among acos and found, for example, that only 80% of patients that were assigned to one aco in one year were assigned to the same aco in the next. that's just over a two-year period. among the high-cost patients that number was even lower, about 75%. so that instability, that churn in the assigned population, suggests diminished returns on investing, in specific patients. a lot of specialty care leakage, so even among the most specialty oriented acos we found that over half the specialty office visits

were occurring outside of the acos. and then something we termed contract penetration, the proportion of outpatient care revenue that's devoted to the patients under the risk contract, that was only 40% in our study. so that suggests very weak incentives to roll out or implement changes that might spill over onto other medicare patients. and we think that those spillovers are probably likely, for example we found spillovers in massachusetts from the alternative quality contract which is a commercial aco contract sponsored by blue cross blue shield onto the medicare population. then lastly -- so those are two challenges that require some rule changes if not some developments in the market, like

medigap select plans oriented around acos to help sharpen the incentives. and then thirdly, despite those weak insent sieves in the constraints that acos face the results have been quite positive. i think there have been some fairly convincing reports of early savings. we have some results coming out soon, demonstrating a positive impact of the medicare aco programs on patient experiences, including improved or more timely access to care, better overall care ratings among the complex patients that are more likely to be targeted by the care management programs. as well as patients perceiving their care to be more -- better coordinated. so from my perspective i think overall it seems like a good start. but the need for some changes, new developments, to make the program a true win-win both for medicare providers, as well as patients. >> just one before going on to david, just one quick follow-up, is that stated as a resource hypothesis i think you're

basically saying that if the financial -- the new financial incentives created by an aco program are pretty weak because of things like turn or shared savings, and no downside risk and the potential for losing out on that contract. and the subsequent year, you're not going to see very big effects. you have done some work, as you mentioned with the aqc, the blue cross alternative quality contract, which is, i would think, bigger, in terms of those kinds of financial incentive measures, there have been bigger effects there, are you willing to say anything about whether doing more in terms of these kinds of strengths of incentives will lead to bigger effects, is there evidence for that? >> so the aqc doesn't have that rebasing involved. so if an aco is looking over a longer time horizon the incentives are certainly stronger. i think that's true among most of the commercial aco contracting. so there's a negotiated budget, and it will stay there, or there's at least no rule saying

it will get ratcheted down every time savings are achieved. the aqc is rather interesting in that it was implemented in a country broad hmo network. so there are no restrictions, or financial incentives for patients in the aqc to go to the participating aqc provider groups. there are, however, mechanisms, because it is an hmo plan for providers to deny care outside, because they do need -- they need to have primary care doctors, and the pcps can approve or deny referrals. anecdotally it sounds like the aqc groups, the provider groups have successfully without those financial incentives been able to corral care in and contain it within their provider groups. man of those groups are quite large. >> and more effect on savings as well as quality? >> right. and so the other from the aqc is real savings effects and real improvements in quality. so whether that's related to the stronger incentives or not i think just remains to be seen. it's massachusetts.

so, that's also a potential difference. >> still need more research. and i know david you've been doing a lot of work around the country on this. really appreciate your perspectives on what the research has shown to date. >> so i'm going to focus on three different areas. the first is the variability among acos. so when we talk about accountable care it's often referred as somewhat of a homogenous group of providers, but, in fact there's a lot of variability among them. there are acos that have 30 physicians and there are acos that have 30 hospitals. as you can imagine they have very different needs, concerns and approaches to managing a population. and so what we're starting to see is that when you talk about accountable care it needs to be subdivided into the different aspects of the providers that are participating.

and the reason for that is because they really have a different glide path. they have a different opportunity to progress toward achieving the same common objective. so if we want to provide better care, we want better patient satisfaction, and lower costs, it can be achieved, but with different provider types they're going to focus on different things. and they really should prioritize different things from day one. so that's one of the challenges, is that many of the acos are focusing on topic "a," when really given their individual structure they should be focusing on topic "b." the second area talks with the real challenge of becoming an aco and managing populations. there are two kind of core broad groups of acos. some of those have been in effect acos for a long time. they've been managing populations, they have relatively integrated services. they have somewhat developed h.i.t., and then there are those organizations that have been strictly fee for service shops in the past and they're trying to make that transition. what we found is that it's a long and hard transition to become a population focused provider group. so it's not something that we expect organizations to make that transition over the course of the first year.

it's not even something that's necessarily going to happen within three years. it's going to be an ongoing challenge. some of the big challenges that they mention are obviously the h.i.t., what they should invest in, and when. but probably the biggest challenge is just giving the provider buy-in. so you can imagine if you have a group of physicians that have been working on a fee for service basis for the past 20 years and you say now we need to focus on a population, getting them to change their practice patterns, getting them to work more as a team, getting them simply to change the referral practices, is a challenge and it

takes a lot of time and effort. and so while we'd like to see results in the first year and have a good indication of whether acos are going to work or not, one year really isn't enough time before trying to evaluate the organizations that are trying to make that transition. the third thing to talk about is the strengths of the different types of accountable care programs. so medicare, medicaid, and the commercial. medicare what i really view as an enabling program. it has a relatively low threshold so providers are able to go in and start to focus on population health in the short-term. also, if you only have -- if there's no downside risk, there's not a huge financial barrier or disincentive to enroll.

and so while there are start-up costs, it's really a way to enable a lot of providers to start to bear risk and experiment with this. on the commercial side, we think of this as a program that allows additional resources to the acos. a lot of the large commercial payers out there have a series of different contracts that they work with providers on. so initially they're not in a full risk bearing contract. they're not a full-blown aco. but they'll do pay for performance bonuses but it's a stepwise progression. where over a period of years they help train the providers in the skill set necessary to manage a population. and so it's really a longer-term track as opposed to just jumping in and being an aco right away. on the medicaid side, this is really where i see there's a lot of opportunity for states to push the accountable care movement. and the reason for that is that they have a disproportionate

ability to force providers into bearing risk. and so where we've seen these states that have a strong focus on accountable care, we're seeing a lot of activity both within the medicaid space, and also outside of the medicaid space. as providers are being forced to consider becoming an aco for the medicaid program, they'll want to look for other opportunities to experiment, and so those where they're afraid that the medicaid program will move that way, the providers, for example, are more willing to just enter into the medicare program. the last thing that i would make is that aco growth within a market has not happened by itself. there's very much a lot of strong market dynamics at play. and you don't see an isolated aco. when there's one aco all of the competitors in the market either form an aco right away, or create an aco plan over the next few years. and so, within individual markets, there's a lot of overlap in terms of the

different providers that are participating, and it really is happening at a market level. not just at the organizational level. >> david, thanks for summarizing a lot of evidence and experience quickly. you know, i just follow up on the point about states and medicaid program. you mentioned a lot of activity, including some fairly significant reforms, away from fee for service payment. anything you can say about actual results from some of those programs so far? they are pretty early. >> sure. the one good example is oregon. they've, what we would consider to be most aggressive tactic in moving their entire medicaid population to ccos, or care coordination organizations. and they have seen generally positive results. they are mixed. but they are somewhat positive. there are a number of other states that are just starting this year to move their population or next year even or the next few years, and so it really preliminary results even earlier than the shared savings program.

>> yeah. i think particularly that point about the fee for service transition, and it being a painful one, spending a lot of time in california, i think sometimes, you get a little bit isolated, we're surrounded by groups that have been in capitation, managed care, heavily so for a long time. and then when i have the opportunity to come out of the state, and meet folks who really have a managed risk, and you really begin to get a sense for what that really means. you don't have any of the infrastructure that any typical organization provider group that i would encounter in california, in other states where there's just fee for service, or heavily fee for service, they never had to adapt. they've never had to develop these services. and so, beyond what happens at the provider mentality level, by the organization that's

supporting them, there's a lot of work to be done, and that takes a lot of time, a lot of investment. but one point i do want to make, which i think is important, as a physician, one opportunity that i hope is not squandered in this, is that the fee for service churn is so disaligned for the patient, and the provider. and there really is an opportunity here where folks can get the right care with the right person at the right time. physicians, if they're willing to give up aly bit of their autonomy, and work in a team-based approach, will be able to spend more of their time working to the top of their license, and most importantly, spend a lot of time talking to the patients who really need them the most. i mean that's what really drives me. what really motivates me to see

this work through. unfortunately at that, we've got a great group of physicians in our provider group, and i think that, more than anything, has to do with our success. but that's what i really worked towards. >> just like to delve on that. david's comments on what does it take to change culture of an organization. so you've heard, you know, some examples shared in terms of physician culture. we, too, while we've had ten years of experience working with our physicians to improve quality to our clinical integration model, it's been a shift for our organization to now take a perspective outside of the four walls of our hospital, and to do that we created what we call an advocate care index, population based measures that all of our senior executives down to the director level, as well as in the physician side, create alignment for the organization to move forwards improving overall quality and cost of care regardless of where that care is delivered. and the physician office, you know, the points about patients supporting staff to practice at the top of their license, a cultural shift for our organization, you know, has been actually physically placing care managers that we hire into independent physician offices. so that's a big shift in dynamics, in that office space environment. >> and back to michael's comments about the shift in your financial support to make those kinds of business models sustainable. i expect there's some challenges around especially being a hospital-based system where a lot of the revenues have come from the kind of procedures that

michael is highlighting, is maybe getting that revenue getting in the way of making some of these changes. how have you dealt with that? >> yeah, so, it's -- clearly the model needs to move towards take ing cost out of the system. i think that was the comments earlier about evidence based practice, reducing unnecessary use, so that's a component of it. there's also a component of how do we achieve greater economies. and, you know, part of that scale in terms of an organization, but also looking at greater efficiencies in terms of systematic change, marketing services, human resources, those types of aspects, supply chain. so we're on a three-year journey to take out about 2% of operating costs each year to make sure that the model is

sustainable. >> i'd like to open this up to discussion from the audience, as well. sort of a question in the back there. we'll bring the microphone over. >> josh sideman, from the advelair health. dr. mcwilliams it was really interesting the comments you were making about the beneficiaries experience of care. i'm curious if you are actually also the providers from the groups, have any insight into whether some of the incentives in the sometimes critiqued cms approach to beneficiary attribution and assignment are having an impact on how you're engaging beneficiaries. >> so it's hard to know from the empirical analyses, we've done what's specifically mediating the changes in patient

experiences that we observed. as far as the mechanisms for patient engagement go, i doubt they're playing a big role. my understanding is that most medicare beneficiaries are unaware that they're even in an aco. they get this letter about data sharing that some are confused by, and some throw away, and some opt out of. but the patient experiences that are in the quality part of the aco contract are very much more along the lines of caps measures. overall ratings of care, and physicians, and how access to care is. whether physicians are interpersonally connecting with them. whether their care is coordinated. those are things that i think the acos are probably impacting more through the systems that they're putting into place, whether it's new scheduling referral, access systems, care management programs that are really focusing on the needs of the complex patients.

rather than anything going on between medicare and the patients. now, this does beg the question now how will patients view the medicare aco programs? i think certainly one concern is that if patients do not like the brand of care that acos are providing, then that would not bode well for the programs because they are voluntary and that could lead to market share losses and maybe discourage groups from staying in the programs. >> michael, marcus, how much do your patients know that they're part of accountable care arrangements, or are they just experiencing care differently for other reasons? >> yeah, i think it definitely varies, and there's truth in that there are beneficiaries who probably don't realize that they're in the program. patient engagement is definitely a key element that needs to be executed on to be successful. and we also participate in some other cmmi innovation projects like iocp. so i've had a lot of discussions

with other provider groups, and it's interesting. the medicare population is not one size fits all. that there is regionalism even down to the level of certain cities. so like for our group, reaching out, sort of cold call style to beneficiaries was not well received. whereas in other communities, that was acceptable and they were able to get patient engagement. so we generally had to kind of circle back around to our providers and work through those offices to get to those patients, and i think to your comments, that as far as patient experience goes, i think that we have put a point of emphasis in the provider groups for patient satisfaction that get score cards every quarter. it's part of their bonus incentive program. so there has been some attention and some improvement there. but a large part is, as you were saying, you're creating a large

organization behind the providers, and the patient experiences all of that. and that is generally good. so that's a good thing. that's coming out. even if it's not directly soming from medicare, or directly coming from the provider's office, per se, patient is still benefiting. >> and david, from your -- you highlighted the different types of acos and how that might mean different steps that they should take to achieve some of the goals. presumably better patient experience is a key goal for all of them. any comments about differences that you're seeing, and how they're approaching the challenge of more effective patient -- patient engagement and experience? >> one observation is that i agree with michael that there's not really that focus on telling them that they're part of an aco, but it's really the benefit of the view by what are the providers serving. they say we're going to provide additional care coordination. we're going to provide enhanced access with primary care. but it's not saying you are part of an aco now. that's not the marketing

strategy. across the groups it really does vary. and it also varies across organizations. some really don't put the -- excuse me, the patient engagement as a high priority. others are trying to build their entire strategy around that. so a lot of variability across organizations. >> thanks. next question, up here. and then in the back. i'm dr. carolyn coughlin a primary care physician and an attorney, and this is actually a follow-up question. i'm perplexed by the fact that you, the acos, many of them are getting high satisfaction ratings, and you're also having trouble with churn. that people are drifting outside the aco. and usually sick patients who are happy with their care, what they're concerned about is being forced to change their provider, rather than -- they want to stick with providers who know

them and that they know. so i would think that would reduce churn relative to a sort of a wide-open fee for service. and i'm curious about who is drifting away. and if you looked into why. >> i can address that. >> okay. >> so, what you're talking about is the attribution methodology, and the joke i have is that attribution is the languagest four-letter word in health care right now. it's an evolution in terms of how much data is being used, and into the methodology, and the logic. and i think that fundamentally is the issue at hand. and so, what we experience at pioneer over the first two years is about a 30% turnover rate. between people going out and people coming in. so, it's -- and i get, doctor, the question that you're asking. and it's just -- it's not as simple as that and it's not just

about the relationship between the patient and the provider. it depends on, for instance, what doctors did you put into the attribution level. so for instance, we have 1700 physicians in our network. but only 300 of them are part of the pioneer aco. and that was a strategic tactical decision that we made. so that's one aspect of it. there were some rules in the beginning about visits, how frequently they were occurring, and if they weren't occurring you would lose the attribution. so that plays a role, as well. so it's -- and actually we found that for folks who aren't technically attributed to us, they're still going to see our physicians. they're still connected in our network, and that's not going to

be true for, say, orange county where there's tremendous amount of competition. more provider groups competing. the bay area, san francisco, is a little more concentrated. so there's a number of factors that go into it. and i wouldn't take what you're hearing as an indication of dissatisfaction from patients. it's more about the attribution methodology. >> other comments on this? i know the attribution methodology and this issue of relationship to churn, and relationship with churn to beneficiary dissatisfaction is an important area. and all of you have thought about this. >> i might just add that if there is increased satisfaction, then it may very well decrease the churn. i don't think we know that. we don't have a good handle on that. but there may be a sizable effect from that. and the other -- i make one other point, which is that i think sometimes the knee-jerk response is to fix the attribution methodology. but that probably won't accomplish a whole lot without addressing the fact that

beneficiaries assigned to an aco have unrestricted choice of providers without any incentives to direct them back to the aco providers and we just know there's tremendous care dispersion among beneficiaries in part for that reason. and that's sort of what the acos are up against. >> other comments on this? okay, great. a question up here. in the front of the room. >> hi, morey menacker from hackensack. i heard sean discuss very, very briefly information, and his comment was that monthly they were supplying claims data to the acos. but we all know that the claims data from cms can be up to 12 months delayed. so even if you're getting it

monthly, you can't accurately predict what's happening with your population and make changes. now, we've had some brief discussions about health information exchanges, and data sharing. but it seems clear to me that the successful organizations, be they acos or not, are able to share data, clinical data, and be able to make appropriate decisions based upon that information. but yet, the government, with all its regulations has absolutely no regulatory oversight over electronic medical records and transfer of information. and has sort of left that to the private sector. the question is, is there a mechanism that we can utilize to improve data sharing to be able

to really change our ability to quantify best practices and minimize wasteful spending. >> you think we're going to come back to policies, new policies around information technology and data sharing later. i would like to ask both michael and marcus emphasize the importance of information technology in everything that they're doing. but, what is the state of the research evidence on the extent to which better access to data, whether it's through health information exchanges or other areas translates into better or greater success of the aco effort? or is that just another area where the research is limited? i'm asking david and michael to start. >> so, this is more observational data. the first is that, information technology is still very much a work in progress with most organizations. so, most of them have an emr that works. they're able to look at patient

level data, being able to aggregate that to a population and track that over time is more challenges. there's a lot of investment right now going into predictive analytics and care management platforms. but whether or not they're choosing the right platform or doing it at the right time is still to be determined. so there's a lot of kind of push and pull among acos about how they're going about this. one other observation about information exchanges is that the primary focus of the organizations is sharing information within the organization as opposed to sharing between organizations. the focus is trying to keep people in network and communicating between people that are quote/unquote on the same team. and so the focus right now is how do you make sure that your outpatient is talking to your in-patient. particularly when you might be on different emrs. we know of acos that have over 20 different emr platforms. they're just trying to integrate and speak amongst themselves,

let alone trying to bring in all the other outside platforms. >> i would just add quickly it's a major research challenge. and i think that the data that david's group, for example, is collecting will be a major contribution to allow really rigorous analysis on that. >> and michael and marcus, any final thoughts on working effectively with cms data? >> yeah. we've spent a lot of time working with their actuaries trying to sort of solve the black box. i think one last closing comment i would want to make is, value-based purchasing is here. there was a lot of hand wringing back with the election in the supreme court case, but by that point, particularly with deals like what devita did, it's very clear the marketplace has spoken. and folks that are the doing fee for service now have got to start changing their ways. because this is coming. it's in medicare fee for service. it's in commercial now, and so it is imperative for their survival really that they start making the changes we're talking about here today. >> any other final thoughts on the panel? >> it is with this past-moving area, and this fast-moving attention around value based payment it is a very challenging

area for the research to keep up. and we very much appreciate the discussion that all of you had about the state of that research and its implications for further steps with acos. so i'd like to ask all of you to join me in thanking our panel for an excellent discussion. [ applause ] all right. we are now going to take a short break until about 10:45. we'll reconvene with our next panel on big issues for acos going forward. as you can tell there are a number of them. thank you. >> new york democrat carlin mccarthy. here is what the congresswoman hases to say about the future of the party's leadership pt >> we have a lot of talented younger members. it's not just, by the way, mrs. pelosi. she's been a great leader. she's really good at raising money. that's not one of my fortes. i was never good at that.

but they have to start training younger people and bringing younger people into the caucus to become hopefully future leaders. one of the things that i believe with all my heart and soul, you have to know when to leave. nancy obviously doesn't feel this is the time to leave. many of us thought she might stay for, you know, maybe this coming year. hopefully turn the reign reins o someone else. but when i look around, is anyone ready to replace her? it's a hard job. i give her credit. but it's time that the leaders, you know, start looking at who's going to fill my spot? we're all replaceable. there might be bumps in the road. i do always believe it's time for younger people to take our spots with fresh ideas and new

ways of doing things. i see nothing wrong with that. that's a progression, a normal progression. >> you can see congresswoman mccarthy's full rarks and our interview with tom petry tonight at 8:00 eastern on c-span. tonight, on "the communicators," tim wong, founder and ceo of fisle call nook on their technology that predicts outcome to congressional legislation using data mining and artificial intelligence. >> our analytics get more granular than seeing whether or not something passes. we can break down on a legislator basis how likely they are to vote for a certain bill. from a tactical perspective there is a lot of opportunity for attorneys, lobbyists, whatever to go in and say, let me look at the bill. based on the cosponsors here are the 50 people most likely to vote for it, those least likely

to vote for it. you can look at developing a strategy in terms of trying to get at the information you need. what i will say is that, you know, our an lytics don't provide all the answers. with that being said, there is a lot of power being able to combine the an lytics with raw industry or human intelligence. they should get to the answers you would like to get to. >> the brookings institution concludes with the panelists on ocos. this is about 50 minutes. >> i would like to welcome all of you back to brookings on the

state of accountable care. we had a chance to hear this morning from shawn cavanaugh on where accountable care is headed and a panel of expert researchers on the evidence so far and we are moving into the next panel. an on the ground look at big issues for acos going forward. we want to turn to the major challenges on the ground for existing and new acos as they implement changes in practice and as they move forward on engaging and activating patients. they take steps towards the culture change around improving care and focus on value as you heard. there was an emphasis on patient experience and engagement about

some of the challenges to that based on both the way that americans have gotten health care and challenges related to the payment system. on the other hand, patients have been skeptical about being engaged in payment forums, but too often end up seeming more focused on cost and access. this is the set of issues around challenges for the success and they are definitely focused on some of the challenges around, wooing with patients in new ways in these new kinds of care mottles. i highlighted the key challenge facing accountable care today. related to this are payment formulas. it is different than paying based on volume and intensity.

the methods are evolving and may not be as aligned as they could be with the key goals. we talked about bearing financial risk. the advantages of moving from shared savings to more of that first ability to redirect resources and the concerns about skimpying or access to care and managing they help address those that are smaller and don't have a lot of those. they have ways of combining the reforms like medical home changes and other value-based

payment reforms and identifying best practices for clinical transformation. this is hard work as you heard and the best step forward depends very much on market circumstances and their own characteristics. this makes it a challenging task to undertake. we have a panel to discuss these key issues related to accountable care organization success going forward. this includes and i will introduce them now. jennifer sweeney, the vice president at the national partnership for women and family where she works with foundations and health care providers and consumers and others. they improve the quality and efficiency and the centeredness.

they have multistakeholder engagement in the processes and intended to achieve the goals and a deep knowledge of delivery system models and quality improvements for strategies aimed at high quality health care. next is kelly taylor, the director of quality improvement for mercy clinics. she received her bsn and msn from the university of iowa. nationally certified in case management with over 15 years of case management and disease management experience. she is getting firsthand experience with the challenges and opportunities around engaging patients more effectively. finally the chief executive officer. maury has been a member since inception in 1997 and worked

there on getting a multidisciplinary approach to help them become papers and engaged on the ground in trying to implement the reforms. i will start out asking the panelist to make an opening or framg comments and we will have a back and forth discussion. i would like to start with you, please. >> i enjoyed the presentations. i work for women and families and we have been around for more than 40 years working on health care issues including delivery reform. we have historically been supportive of new thrivy mottles that have the potential to

improve cost and patient experience. we looked at them as a potential benefit to consumers and to patients. i think like the provider community from the beginning, we had concerns about acos and you touched on some of them. the two biggest we had is this would devolve into just a financial mechanism instead of transforming care clinically. the second concern we had was on the issue of patient engagement. sometimes when people talk about it, it sounds like we are looking for them to be better patients rather than looking at an opportunity for health care providers and leaders to partner at multiple levels. as we look across the landscape

and they talked about the variability in terms of the two years. we think some are looking at this as an opportunity to transform care clinically. some are partnering and being better patients. my sense is that a lot of acos have shelved those two issues. i understand that i think to some degree, the financing and the measurement and the attribution, but as i look forward into the future in my mind this mottle won't realize potential without the focus on the trance formation and patient engagement. i will talk about the piece. there four levels that we see. first at the direct care level

and things like share decision making. it's interesting when i talk about including beneficiaries on the gor earning bodies on the way to help them understand what it is patients need and want. i see a lot of confusion and lack of interest. the second piece is papering with them at the design level. we know that some are doing a really good job of not just surveying about their experiences, but forming patient and family advisory councils and working with the numbers to codesign the care. at the other level the community level. in my experience and health care providers in general don't

partner with the organizations like meals on wheels. those are critical to doing transitions. the last thing i want to speak to is the concept of whether or not patients will stay in an aco and how we help them understand. the concept of marketing to patients about it. that's a misguided approach. we need to take a building awareness and education approach net. patients don't need to be sold if they are getting that patient centered care they need and want and if they are being partnered. >> thanks very much. >> my name is kelly taylor and i'm the director of quality and